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P - 35182Builc�ing Inspections 763-572-3604 763-502-4977 FAX DATE__ /�� // SITE ADDRESS � TH[S APPLICANT [S: PROPERTY OW1vER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE AND CERTIFICATE OF INSURANCE PROPERTY TYPE BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTNE 1-1-20ll YO�UpR E-MAIL ADDRESS /P� OWNER ❑'CONTRACTOR Permit No.:����� Received By;� Date Rec'd: � ( �� t � ` NAME: A/°! QZ ADDRESS: �D ��O �12 /�CJ'Yl /// �Sl-/ v � CITY �!(LIP�( STATE�ZIP��� PHONE:_��j3—S�y �--�� 6 H'i IOIZ'-3ZS- .5��63 � � NAME: c �r'� STATE L[CENSE PHONE (�l'!L^ (7[�7� ZKbL 6ZSINGLE FAMILYJNEW CONSTRUCTION ❑ TWO FAMILYMEW CONSTRUCTION PERMIT TYPE I � �DITION ❑ BASEMENT FINISH �DECK TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION � MAINTENANCE/REPAIR DESCRIBE WORK BEING ROOFING NUMBER OF SQUARES _ GARAGES PROPOSED SIZE: PROPOSED HEIGHT: IDING ❑ Vinyl ❑ Aluminum 0 Other LEAD CERT NL)MBER CITY STATE�ZIP�2 FAX SIZE ❑ ROOF ❑ DRAIN TILE ❑ SIDING ❑ OTHER ❑ SWIMMfNG POOL �ADDITION � REMODELING ❑ HOUSE ONLY ❑ HOUSE & GARAGE ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑Soffit O Trim ❑ Fascia WINDOWS IN EXISTING OPENMGS ❑Yes ONo LACATION OF WINDOWS OR FOR NEW OPENMGS-DESCRIBE SIZE OF OPENING CHANGES & � � BASEMENT REMODELING SUBMIT: I. Existing Floor Plan 2. Proposed floor plan 3. List of structural members to be used FOR NEW CONSTRUCTION MCLUDTNG DECKS, ADDITIONS. & PORCHES SUBMIT: 1. Site P{anlSurvey showing the existing structures and proposed project. 2. Two sets of construction plans 3. Energy Calculations FOR WINDOWS - PROVIDE U-VALUE AND MANUFACTURE STICKER ON WINDOW. TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS ' � ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: � (USI�G THE 1997 U.B.0 FEE SCHEDULE) fOTAL JOB VALUATION $ °C� a� Ir� � OCCUPANCY TYPE Permit Fee Plan Review Fire Surcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due $ $ $ $ $ $ See Back Page for Fee Schedule 65% of Building Permit Fee .001 times the total job valuation .0005 x Permit Valuation Minimum $5.00 $5.00 (State Licensed Residential Contractors) $2230 per SAC Unit (Plans to MWCC for determination) ft+6ft= ftx$25=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks �avable to: Citv of Fridiev Attach THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the approved plan in the case of al �or w�c qu�res review and approval of pla!n�. �y SIGNATURE OF APPLICANT �• ��� PRINT NAME t7h7Nlly ��f'7ZZ DATE 7-�75 " II APPROVAL INSPECTOR SIGNA RE . ,rt� s'------ . . 0 CERTI�ICATE �F S��VEY � . � � r� j.i � ..� i i.l� ;C . . � 1 �L�� _ �� �I � -.�, ���r �� _ _�.�__ , I � 2S � 120(.00 ' .� .. ,.�;... s3 a � � s �.- ; j 61 �s �. 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